Hernia https://doi.org/10.1007/s10029-018-1729-9
INVITED COMMENTARY
Summary for patients: International guidelines for groin hernia management N. van Veenendaal1 · M. P. Simons2 · H. J. Bonjer1 Received: 1 January 2018 / Accepted: 4 January 2018 © Springer-Verlag France SAS, part of Springer Nature 2018
Who developed these guidelines? An international working group of 50 hernia experts called ‘HerniaSurge’ developed the first international guidelines for groin hernia management. All experts have extensive clinical and scientific experience in hernia management. The guidelines were endorsed by seven continental hernia societies: Afro Middle East Hernia Society (AMEHS), Americas Hernia Society (AHS), the Asia Pacific Hernia Society (APHS), the Australasian Hernia Society, the European Association for Endoscopic Surgery (EAES), the European Hernia Society (EHS) and the International Endohernia Society (IEHS).
What is the problem and what is known about it so far? Groin hernia repair is one of the most common surgeries performed globally, with more than 20 million procedures a year. There are many different approaches, treatment indications and a significant array of techniques for groin hernia repair across the world. Despite the magnitude of the number of hernia repairs performed, international guidelines do not exist. Several surgical societies have written guidelines on groin hernia repair, but none have been developed with a global scope. HerniaSurge decided to write a set of international guidelines on groin hernia management. The objective was
This comment refers to the article available at https://doi. org/10.1007/s10029-017-1668-x. * N. van Veenendaal
[email protected] 1
Department of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
Department of Surgery, OLVG, Amsterdam, The Netherlands
2
to standardize care, minimize complications, and improve results in groin hernia management.
How did HerniaSurge develop these guidelines? The HerniaSurge Group analyzed and examined all available literature on groin hernia management. Statements and recommendations were formulated based on best available evidence. When evidence was insufficient or lacking, recommendations were either formulated based on expert opinion or a recommendation could not be made.
What did the authors find? Groin hernias occur due to muscular weakness in the lower abdominal wall, resulting in bulging of abdominal contents. It is estimated that 27% of men and 3% of women will develop a groin hernia during their lifetime. Patients can have a symptomatic groin hernia with complaints of pain or discomfort, or can be asymptomatic. Diagnosis of a groin hernia can be confirmed by physical examination alone in the vast majority of patients. Rarely, ultrasound is necessary. Patients without symptoms or with minimal symptoms may be managed with “watchful waiting”, but the standard of care for a painful groin hernia is surgical repair. Surgical treatment should be tailored to the surgeon’s expertise, patient- and hernia-related characteristics and local/national resources. Regardless of the choice for open or laparoscopic (keyhole) repair, the use of a mesh is recommended because the chance the operation fails and the hernia comes back (= recurrence) is greatly decreased. However, after appropriate discussions with patients, repair without mesh can be offered especially in certain centers that specialize in non-mesh repairs. Day surgery (outpatient surgery) is
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recommended for the majority of groin hernia repair provided the patient has an appropriate support system at home. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. The majority of the patients are comfortable within 1–2 weeks. A minority of patients have complications such as a fluid collection in the operation site, wound infection, temporary difficulty urinating, recurrence or chronic pain/sexual dysfunction. Approximately 10% of the patients after groin hernia repair will develop chronic pain (pain lasting more than 3 months), which will decrease over time. In 0.5–6%, chronic pain will be severe and affect normal daily activities or work. In that case a visit to the surgeon is recommended to discuss treatment options.
What does HerniaSurge recommend that patients and doctors do? Each groin hernia management strategy should be based on surgeon’s expertise, local/national resources, and patientand hernia-related factors. The international guidelines on groin hernia management can be taken into consideration, but the definitive treatment plan should be based on shared decision making between the surgeon and patient.
What are the cautions related to the guideline and recommendations? The guidelines provide an overview of the best-available evidence on groin hernia management and provide statements and recommendations for daily practice. The international
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guidelines for groin hernia management are meant to guide in the decision making process. If surgeons choose not to follow recommendations that are endorsed by experts, they should do so in consultation with their patients and document this in the medical record. Funding This project was funded by Johnson & Johnson and BARD.
Compliance with ethical standards Conflict of interest N van Veenendaal and M.P. Simons report grants for meeting expenses related to the submitted work from Johnson & Johnson and Bard, during the conduct of the study. H.J. Bonjer declares conflict of interest not directly related to the submitted work by receiving grants from Johnson & Johnson, Medtronic, Olympus, Applied Medical and Stryker; and by receiving personal fees from Medtronic, Olympus and Cook and reports grants for meeting expenses related to the submitted work from Johnson & Johnson and Bard, during the conduct of the study. Ethical approval This study did not need approval from the local ethical committee. Human and animal rights This study does not contain any studies with participants or animals performed by any of the authors. Informed consent Informed consent was not required for this study.
